Inspection Reports for Lifespace Communities Inc
8101 MISSION ROAD, KS, 66208
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 19, 2024, found the facility in compliance with all regulations and no new deficiencies. Earlier inspections had cited multiple deficiencies related to care planning, pressure ulcer prevention, resident safety, staff performance reviews, medication management, antipsychotic medication use, and food service safety. Prior complaint investigations were mostly unsubstantiated, with the exception of a substantiated case in 2016 involving failure to implement a physician-ordered chair alarm that resulted in a resident fall and injury. Enforcement actions included denial of payment for new Medicare admissions in 2015 due to deficiencies at a level of actual harm that was not immediate jeopardy. The facility appears to have made improvements over time, correcting prior deficiencies and maintaining compliance in the most recent survey.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
10.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
37 residents
Based on a February 2024 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 19, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-02-27.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2024-04-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 7
Feb 27, 2024
Visit Reason
This document is a Plan of Correction submitted by Claridge Court in response to deficiencies cited during a regulatory inspection conducted on 02/27/2024.
Findings
The Plan of Correction addresses multiple deficiencies related to care planning, pressure ulcer prevention, resident environment safety, staff performance reviews, medication management, antipsychotic medication use, and food service safety. The facility outlines corrective actions including care plan updates, staff education, audits, and monitoring schedules.
Severity Breakdown
D: 5
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to maintain comprehensive care plans including restorative care services. | D |
| Failure to ensure care to prevent pressure ulcers and promote healing. | D |
| Failure to maintain a safe resident environment and adequate supervision to prevent accidents. | D |
| Failure to complete regular performance reviews and provide in-service education for Certified Nurse Aids. | F |
| Failure to ensure residents' drug regimens are free from unnecessary drugs and adequately monitored. | D |
| Failure to ensure residents do not use antipsychotic medications unless necessary and properly documented. | D |
| Failure to store, prepare, distribute, and serve food in accordance with professional food service safety standards. | F |
Report Facts
Audit frequency: 4
Audit frequency: 3
Performance review timeframe: 30
Plan of Correction completion date: Overall Plan of Correction to be completed by 04/11/2024
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 7
Feb 27, 2024
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to revise care plans to reflect restorative services, improper maintenance of pressure ulcer prevention equipment, failure to ensure accident-free environment due to wheelchair foot pedal use, lack of yearly CNA performance evaluations, inconsistent monitoring of medication effects, failure to document rationale for psychotropic medication use, and unsafe food storage practices.
Severity Breakdown
SS=D: 5
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to revise Resident 7's care plan to reflect implemented restorative services and goals. | SS=D |
| Failed to maintain Resident 2's low air-loss mattress pump settings at the correct weight range, increasing risk for pressure ulcer development. | SS=D |
| Failed to ensure an environment free from accident hazards by not utilizing wheelchair foot pedals while transporting residents 18 and 22. | SS=D |
| Failed to ensure yearly performance evaluations were completed for five Certified Nurse Aides reviewed. | SS=F |
| Failed to consistently monitor Resident 4's pulse before administration of carvedilol medication. | SS=D |
| Failed to ensure documented physician rationale including multiple unsuccessful nonpharmacological interventions before starting Resident 14 on Seroquel. | SS=D |
| Failed to ensure food items were properly stored in a safe and sanitary manner, including labeling and dating after opening. | SS=F |
Report Facts
Census: 37
Sample size: 12
Sample size: 5
Medication dosage: 3.125
Medication dosage: 12.5
Weight: 109.6
Mattress setting: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Stated pulse should be monitored before carvedilol administration and discussed medication effects. |
| Administrative Nurse E | Administrative Nurse | Provided statements regarding restorative services, mattress monitoring, accident prevention, medication monitoring, and psychotropic medication management. |
| Certified Nurse Aid O | Certified Nurse Aid | Reported performing weekly upper body range of motion exercises with Resident 7. |
| Certified Nurse Aid M | Certified Nurse Aid | Observed pushing residents in wheelchairs without foot pedals. |
| Administrative Staff A | Administrative Staff | Stated facility did not perform formal yearly CNA performance evaluations. |
| Dietary Staff BB | Dietary Staff | Stated all foods out of original containers should be dated and labeled. |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 22, 2022
Visit Reason
An offsite revisit survey was conducted on 09/22/22 for all previous deficiencies cited on 08/04/22.
Findings
All deficiencies have been corrected as of the compliance date of 08/26/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 6
Aug 4, 2022
Visit Reason
This Plan of Correction document addresses deficiencies identified in the Claridge Court facility inspection conducted on 08/04/2022, outlining corrective actions to be taken to remedy cited deficiencies.
Findings
The facility had multiple deficiencies related to baseline care plans, comprehensive care plans, resident preferences, catheter care, hydration, and infection control. The Plan of Correction details corrective actions including education, audits, and monitoring to ensure compliance and prevent recurrence.
Severity Breakdown
D: 5
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to develop and implement a baseline care plan for each resident. | D |
| Failure to develop and implement a comprehensive care plan for each resident with accurate updates. | D |
| Failure to provide necessary care and services to ensure residents attain and maintain highest practicable well-being. | D |
| Failure to ensure bowel/bladder incontinence and catheter care to reduce infection risk. | D |
| Failure to ensure residents have access to drinking water to promote adequate hydration and nutrition. | D |
| Failure to establish and maintain an infection control program to provide a safe, sanitary, and comfortable environment. | E |
Report Facts
Substantial compliance date: Aug 26, 2022
Audit duration: 30
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Filla | Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 7
Aug 4, 2022
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00165056 to evaluate compliance with care planning, quality of life, incontinence care, nutrition, dementia care, and infection control standards.
Findings
The facility was found deficient in multiple areas including failure to complete baseline care plans, revise care plans for hospice services, honor resident preferences affecting quality of life, maintain catheter care standards, ensure hydration accessibility, provide appropriate dementia care resulting in resident injury, and maintain infection control practices related to catheter and laundry handling.
Complaint Details
The visit was triggered by a complaint investigation #KS00165056. Specific complaints included failure to complete baseline care plans, improper care plan revisions, neglect of resident preferences, improper catheter care, inadequate hydration support, and inappropriate dementia care leading to injury.
Severity Breakdown
SS=D: 5
SS=G: 1
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to complete a baseline care plan for Resident 42 within 48 hours of admission. | SS=D |
| Failure to revise the care plan with the correct hospice company for Resident 20. | SS=D |
| Failure to ensure all staff honored Resident 14's preferences and choices, risking decreased psychosocial wellbeing. | SS=D |
| Failure to maintain catheter bag off the floor and below bladder level for Resident 39, increasing risk of infection. | SS=D |
| Failure to ensure accessible drinking water within reach for Resident 12, risking altered hydration. | SS=D |
| Failure to provide person-centered dementia care for Resident 192, resulting in a wrist fracture due to staff's inappropriate response to dementia-related behaviors. | SS=G |
| Failure to maintain infection prevention and control practices including uncovered laundry transport and catheter bag placement on the floor. | SS=E |
Report Facts
Census: 44
Sample size: 15
BIMS score: 13
BIMS score: 10
BIMS score: 6
Fracture displacement: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Involved in incident resulting in Resident 192's wrist fracture |
| Administrative Nurse D | Provided statements and education related to baseline care plans, catheter care, dementia care, and infection control | |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding baseline care plans and dementia care |
| Certified Nurse Aide N | Certified Nurse Aide | Involved in care of Resident 14 and provided statements regarding dementia care |
| Licensed Nurse H | Licensed Nurse | Provided statements regarding catheter care |
| Certified Nurse Aide P | Certified Nurse Aide | Provided statements regarding catheter care |
| Administrative Nurse E | Provided statements regarding baseline care plans and hospice care plan revisions | |
| Social Services X | Social Services | Completed hospice care plan for Resident 20 |
Inspection Report
Re-Inspection
Deficiencies: 0
May 26, 2021
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 03/24/21.
Findings
All deficiencies cited in the previous inspection have been corrected as of 04/16/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 5
Mar 24, 2021
Visit Reason
This document is a Plan of Correction submitted by Claridge Court in response to deficiencies identified during a regulatory inspection conducted on 3/24/21.
Findings
The Plan of Correction addresses multiple deficiencies including pressure ulcer prevention, catheter care, nutritional status interventions, nursing staffing information posting, and infection control practices. The facility outlines corrective actions, systemic changes, education plans, and monitoring strategies to ensure compliance and prevent recurrence.
Severity Breakdown
D: 3
C: 1
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Inadequate supervision and assistive devices to prevent pressure ulcers | D |
| Inadequate securing of catheter tubing to prevent catheter related complications | D |
| Inadequate interventions to sustain healthy nutritional status | D |
| Failure to post and maintain daily nursing staffing information | C |
| Inadequate infection control practices and hand hygiene | E |
Report Facts
Substantial compliance date: Apr 16, 2021
Substantial compliance date: Apr 1, 2021
Number of residents affected: 2
Number of other residents identified with catheters: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Filla | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 5
Mar 24, 2021
Visit Reason
The inspection was a Health Resurvey to assess compliance with professional standards of practice related to pressure ulcer prevention and treatment, catheter care, nutrition and hydration, nurse staffing, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide pressure ulcer prevention and treatment for Resident 28, failure to secure catheter tubing for Resident 7, inconsistent documentation of meal intake for Residents 28 and 12 with weight loss, failure to post and maintain nurse staffing data, and inadequate infection prevention and control practices including hand hygiene and mask usage.
Severity Breakdown
SS=D: 3
SS=C: 1
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide services to prevent new pressure ulcers and promote healing of existing pressure ulcers for Resident 28. | SS=D |
| Failure to secure catheter tubing for Resident 7, placing resident at risk for catheter related complications. | SS=D |
| Failure to provide consistent documentation for percentages of meals eaten for Residents 28 and 12 sampled for weight loss. | SS=D |
| Failure to post and maintain daily nurse staffing data as required. | SS=C |
| Failure to perform adequate hand hygiene before and after medication administration, catheter care, meal tray delivery, and wound care; failure to ensure proper mask usage near resident meal trays; failure to transport soiled linens in a sanitary manner. | SS=E |
Report Facts
Resident census: 40
Weight loss percentage: 11.08
Weight loss percentage: 10.42
Weight loss percentage: 6.55
Weight loss percentage: 9.07
Weight loss percentage: 4.87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide N | Certified Nurse Aide | Named in catheter care and hand hygiene deficiencies |
| Licensed Nurse G | Licensed Nurse | Named in wound care and hand hygiene deficiencies |
| Certified Nurse Aide M | Certified Nurse Aide | Named in hand hygiene and meal tray delivery deficiencies |
| Licensed Nurse H | Licensed Nurse | Named in hand hygiene and nutritional documentation deficiencies |
| Administrative Nurse D | Administrative Nurse | Named in nurse staffing and infection control deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 12/29/20.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 10, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted in conjunction with a complaint survey #KS00158545 by KDADS on behalf of CMS on 12/10/2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
The survey was conducted in conjunction with a complaint survey #KS00158545.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 10, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted in conjunction with a complaint survey #KS00158545 by KDADS on behalf of CMS.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
The survey was conducted in conjunction with a complaint survey #KS00158545; no deficiencies were cited indicating compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 11/9/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 9, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 2, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) on 07/02/20.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 Focused Infection Control survey.
Inspection Report
Routine
Census: 34
Deficiencies: 0
Jul 2, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 focused infection control survey.
Report Facts
Sample Size: 5
Supplemental: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 1, 2019
Visit Reason
A revisit survey was conducted on 8/1/19 to verify correction of all previous deficiencies cited on 6/20/19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 7/19/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Jun 20, 2019
Visit Reason
A Health Resurvey and Complaint Investigation was conducted due to multiple complaints alleging abuse and failure to suspend a staff member after an abuse allegation.
Findings
The facility failed to prevent potential further abuse by not suspending the alleged perpetrator immediately, placing all residents in immediate jeopardy. Additionally, the facility failed to identify and implement adequate interventions to prevent falls for residents #1 and #24, both at high risk for falls.
Complaint Details
The complaint investigation involved multiple complaint numbers (#KS00138693, #KS00138489, #KS00136142, #KS00136583, and #KS00142476) related to abuse allegations. The immediate jeopardy was removed after the alleged perpetrator was suspended and staff received abuse training.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to suspend a staff member after an allegation of abuse, resulting in immediate jeopardy to residents. | Immediate Jeopardy |
| Failure to identify and implement adequate interventions to prevent falls for resident #1. | — |
| Failure to identify and implement adequate interventions to prevent falls for resident #24. | — |
Report Facts
Census: 39
Fall risk assessment scores: 16
Fall risk assessment scores: 23
Number of residents reviewed for accidents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Administrative Staff | Acknowledged delay in suspending staff M after abuse allegation |
| Administrative Nursing Staff D | Administrative Nursing Staff | Acknowledged reassignment of staff M and lack of immediate suspension |
| Direct care staff M | Certified Nursing Assistant | Alleged perpetrator in abuse incident involving resident #39 |
| Licensed nursing staff G | Licensed Nurse | Involved in investigation and care of resident #39 during abuse incident |
| Consultant rehabilitation assistant GG | Consultant Rehabilitation Assistant | Provided therapy services to resident #1 |
| Direct care staff member N | Direct Care Staff | Assisted resident #1 with transfers |
| Licensed staff member H | Licensed Staff | Described fall assessment and care plan update process |
| Direct care staff member O | Direct Care Staff | Described fall reporting and care plan communication |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 20, 2019
Visit Reason
The document is a Plan of Correction submitted by Claridge Court in response to deficiencies cited in a prior inspection related to fall prevention and resident safety.
Findings
The facility was found deficient in providing adequate supervision and assistive devices to prevent resident falls. The Plan of Correction outlines measures to review fall assessments, educate staff, audit residents at risk, and monitor interventions to prevent recurrence.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and assistive devices to prevent resident falls. | D |
Report Facts
Residents affected: 2
Days for incident report review: 60
Date for substantial compliance: Jul 19, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Filla | Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 11, 2018
Visit Reason
The health survey was conducted as an annual inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 11, 2018
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 2
Sep 16, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the deficiencies identified under regulations 483.30(b) and 483.35(i) were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.30(b) |
| Deficiency related to regulation 483.35(i) |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 4
Sep 7, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #KS00104909 to assess compliance with regulatory requirements.
Findings
The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week on multiple dates. Additionally, the facility did not ensure proper food labeling, use of hairnets and beard guards by staff, and failed to maintain sanitary conditions during food service, including inadequate hand hygiene practices.
Complaint Details
The visit was triggered by a complaint investigation identified as #KS00104909.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week on specified dates. | Level D |
| Failed to ensure proper food labeling, including undated opened food items in refrigerators. | Level D |
| Failed to ensure staff wore hairnets and beard guards in the kitchen area to prevent spread of infection. | Level D |
| Failed to maintain sanitary environment in the dining area, including improper hand hygiene by staff assisting residents. | Level D |
Report Facts
Census: 36
Dates without RN coverage: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Administrative Nursing Staff | Verified lack of RN coverage and commented on staffing policy. |
| Administrative staff A | Administrative Staff | Verified lack of RN coverage and stated facility policy on RN coverage. |
| Dietary staff DD | Dietary Staff | Stated staff were to mark opened food items with an open date. |
| Dietary staff EE | Dietary Staff | Stated staff were to wear hairnets once entering kitchen doors but was unsure about beard guard policy. |
| Direct care staff O | Direct Care Staff | Described hand hygiene practices to prevent infection spread. |
Inspection Report
Re-Inspection
Deficiencies: 1
Sep 7, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Named as contact and signatory related to the survey findings and plan of correction acceptance. |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 19, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report indicates that the previously identified deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 06/05/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) |
Report Facts
Deficiency correction date: Jun 5, 2016
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
May 19, 2016
Visit Reason
The inspection was conducted as a complaint investigation for complaint numbers 98759 and 98189 regarding failure to implement a physician ordered chair alarm to prevent falls.
Findings
The facility failed to implement a physician ordered chair alarm for a cognitively impaired resident, resulting in a fall with a head injury that required hospital treatment. Interviews and record reviews confirmed the absence of the chair alarm at the time of the fall.
Complaint Details
The complaint investigation found that the facility did not implement a physician ordered chair alarm for resident #3, who fell and sustained a head injury requiring hospital treatment. The fall occurred on 3/10/2016, and staff interviews confirmed no chair alarm was in use at the time.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement a physician ordered chair alarm to prevent a head injury fall for resident #3. | SS=G |
Report Facts
Resident census: 38
Sampled residents: 3
Fall date: Mar 10, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct care staff | Interviewed about resident fall and lack of chair alarm |
| Staff H | Licensed staff | Interviewed about resident fall and lack of chair alarm |
| Staff I | Licensed nursing staff | Interviewed about resident fall and lack of chair alarm |
| Staff D | Administrative nursing staff | Interviewed about chair alarm usage policy |
Inspection Report
Abbreviated Survey
Deficiencies: 1
May 19, 2016
Visit Reason
An Abbreviated Survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a 'G' level of actual harm that is not immediate jeopardy. Due to deficiencies cited and a history of noncompliance on the previous annual survey, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency at a 'G' level of actual harm that is not immediate jeopardy | G |
Report Facts
Denial of payment effective date: Jun 8, 2016
Previous annual survey date: May 15, 2015
Noncompliance correction deadline: Nov 19, 2016
Civil Money Penalty threshold: 5000
IDR request deadline: 10
Hearing request deadline: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions and Informal Dispute Resolution process |
Inspection Report
Plan of Correction
Deficiencies: 1
May 19, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Claridge Court.
Findings
The plan addresses the implementation and monitoring of physician-ordered chair alarms to prevent resident injury, including re-education of nursing staff and maintenance of a master log of residents with alarms.
Complaint Details
The plan references a complaint investigation at Claridge Court dated 05/19/2016.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents requiring chair alarms had current physician orders and alarms correctly applied. |
Report Facts
Complete Date for Plan of Correction: Jun 5, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Bingham | Interim Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
May 17, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an "F" level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at "F" level severity related to Life Safety Code compliance | F |
Report Facts
Enforcement effective date: Aug 17, 2016
Provider agreement termination date: Nov 17, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for licensure certification and enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 7, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the deficiency identified by regulation 26-40-303 (2)(a)(i)(ii)(iii) with ID prefix S1174 was corrected as of 06/04/2015. No other deficiencies are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency identified under regulation 26-40-303 (2)(a)(i)(ii)(iii) previously reported and corrected. |
Report Facts
Deficiency correction date: Jun 4, 2015
Inspection Report
Follow-Up
Deficiencies: 8
Jul 7, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously identified deficiencies were corrected by 06/04/2015, with no uncorrected deficiencies remaining at the time of the revisit.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 9
Jun 4, 2015
Visit Reason
This document is a Plan of Correction submitted by Claridge Court in response to deficiencies cited during a regulatory inspection, detailing corrective actions to address identified deficiencies.
Findings
The Plan of Correction addresses multiple deficiencies including mistreatment and abuse reporting, fall prevention and monitoring, accident hazard prevention, unnecessary drug use, food handling, medication transcription accuracy, pharmacy review compliance, infection control, and electronic door monitoring system functionality. The facility outlines corrective actions, systemic changes, staff re-education, and monitoring plans to ensure compliance and prevent recurrence.
Severity Breakdown
D: 4
F: 3
G: 1
E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure all alleged violations involving mistreatment, neglect, or abuse were reported and investigated according to state law. | D |
| Failure to provide necessary care and services to maintain highest practicable physical, mental, and psychosocial well-being, specifically related to fall monitoring. | D |
| Failure to ensure resident environment was free of accident hazards and adequate supervision was provided to prevent accidents. | G |
| Failure to ensure resident drug regimens were free from unnecessary drugs. | D |
| Failure to procure and handle food under sanitary conditions. | F |
| Failure to provide routine and emergency drugs and pharmacy consultation services properly, including accurate transcription of medication orders. | D |
| Failure to have pharmacist review monthly all drug regimens and act on irregularities. | E |
| Failure to maintain an infection control program that provides a safe, sanitary, and comfortable environment. | F |
| Failure to maintain an electronic door monitoring system that alerts staff when doors are opened. | F |
Report Facts
Substantial compliance date: Jun 4, 2015
Frequency of monitoring: 3
Frequency of random inspections: 3
Frequency of weekly observations: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Salierno | Executive Director/NHA | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 8
May 15, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint investigation numbers.
Findings
The facility failed to report unwitnessed injury falls with fractures, failed to perform neurological assessments after falls, failed to ensure a safe environment to prevent falls, failed to properly assess and monitor pain and anxiety medications, failed to follow pharmacy recommendations timely, failed to maintain sanitary food handling and infection control practices.
Complaint Details
The inspection included complaint investigations #KS00080213, #KS00083744, and #KS00079725.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=F: 2
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to report 2 unwitnessed injury falls with fractures in accordance with State law. | SS=D |
| Failed to do neurological assessments on residents after falls. | SS=D |
| Failed to ensure resident environment remained free of accident hazards and provide adequate supervision and assistive devices to prevent falls. | SS=G |
| Failed to appropriately assess pain prior to and after administration of as needed pain medication and failed to assess effectiveness of as needed anti-anxiety medication. | SS=D |
| Failed to wash hands prior to preparing and serving food after contamination and failed to follow sanitary procedures in food service. | SS=F |
| Failed to provide pharmaceutical services assuring accurate administration of Lasix medication. | SS=D |
| Failed to follow pharmacy recommendations timely and failed to monitor and report irregularities in drug regimen. | SS=E |
| Failed to maintain infection control by not disinfecting surfaces according to guidelines and not wearing gloves when exposed to body fluids. | SS=F |
Report Facts
Residents in sample: 21
Falls not reported: 2
Days Lasix not given: 12
Tylenol dose limit: 3
Fall risk scores: Array
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Direct Care Staff | Reported monitoring resident #31 closely due to falls and described fall interventions |
| Staff T | Direct Care Staff | Reported resident #31 ate by self and required stand by assist when ambulating |
| Staff FF | Dietary Staff | Observed failing to wash hands and cross-contaminating food |
| Staff EE | Dietary Staff | Observed failing to wash hands and cross-contaminating food |
| Staff DD | Dietary Staff | Reported expectations for handwashing and food handling |
| Staff J | Licensed Nursing Staff | Observed resident #31 responding to motion alarm |
| Staff K | Licensed Nursing Staff | Reported expectations for neurological checks and pain assessments |
| Staff D | Administrative Nursing Staff | Reported failure to report falls, lack of documentation, and expectations for pharmacy recommendations |
| Staff H | Licensed Nursing Staff | Reported administering as needed medications and monitoring effectiveness |
| Staff JJ | Pharmacy Consultant | Reported expectations for medication monitoring and timely response to recommendations |
| Staff Z | Housekeeping Supervisor | Reported expectations for cleaning and glove use |
| Staff Y | Housekeeping Staff | Observed failing to wear gloves and improper cleaning |
Inspection Report
Enforcement
Deficiencies: 1
May 15, 2015
Visit Reason
A Health survey was conducted on May 15, 2015, by the Kansas Department for Aging and Disability Services to determine compliance with Federal participation requirements for nursing homes in Medicare and Medicaid programs.
Findings
The survey found deficiencies at a level of actual harm that is not immediate jeopardy, with a history of noncompliance from a prior survey on January 23, 2014. Due to these deficiencies, enforcement remedies including denial of payment for new Medicare admissions were imposed effective June 5, 2015.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at a level of actual harm that is not immediate jeopardy | Level of actual harm |
Report Facts
Denial of payment effective date: Jun 5, 2015
Noncompliance follow-up deadline: Nov 12, 2015
Civil Money Penalty minimum amount: 5000
Days to file hearing request: 60
Days to submit IDR request: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Salierno | Administrator | Named as facility administrator in the report header |
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator for the Kansas Department for Aging & Disability Services |
| Gregg Brandush | Branch Manager | Authorized the report as Branch Manager, Division of Survey & Certification, Centers for Medicare & Medicaid Services |
| Jane Weiler | CMS Contact | Contact person for questions regarding the matter |
| Joe Ewert | Commissioner | Commissioner of Kansas Department for Aging and Disability Services, recipient of IDR requests |
Inspection Report
Follow-Up
Deficiencies: 9
Mar 20, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report documents that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected by 02/20/2014, indicating compliance with required corrective actions.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.13(c) |
| Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency related to regulation 483.20(k)(3)(ii) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.25(n) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Correction completion date: Feb 20, 2014
Follow-up survey completion date: Jan 23, 2014
Inspection Report
Plan of Correction
Deficiencies: 9
Feb 20, 2014
Visit Reason
This document is a Plan of Correction submitted by Claridge Court in response to deficiencies cited in a prior inspection report, outlining corrective actions to address identified issues.
Findings
The Plan of Correction details multiple areas of non-compliance including abuse policies, resident care planning, qualified staffing, fall prevention, nutritional assessments, medication parameters, immunization policies, food safety, and pharmacy oversight. The facility outlines specific corrective actions, training, audits, and monitoring to achieve substantial compliance by February 20, 2014.
Severity Breakdown
C: 1
D: 6
F: 1
G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to maintain written policies prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property. | C |
| Failure to encourage and promote resident participation in planning care and treatment. | D |
| Failure to ensure services are provided by qualified persons in accordance with state regulations. | D |
| Failure to maintain a safe environment free of accident hazards and provide assistive devices for fall prevention. | G |
| Failure to conduct comprehensive assessments for adequate nutritional status and maintain therapeutic diets. | D |
| Failure to ensure each resident's drug regimen includes appropriate parameters where necessary. | D |
| Failure to ensure immunization policies meet resident needs and proper documentation is maintained. | D |
| Failure to store, prepare, distribute, and serve food under sanitary conditions. | F |
| Failure to have a licensed pharmacist report irregularities and ensure medication monitoring parameters. | D |
Report Facts
Completion date for corrective actions: Feb 20, 2014
Audit frequency: 3
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Salierno | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 8
Jan 23, 2014
Visit Reason
Health Resurvey and Complaint Investigation KS#70617 conducted to assess compliance with regulatory requirements and investigate complaints.
Findings
The facility was found deficient in multiple areas including failure to implement adequate abuse and neglect policies, failure to revise care plans timely, failure to ensure direct care staff were employed by the facility, inadequate fall prevention and monitoring of wanderguard systems, failure to meet nutritional needs resulting in significant weight loss, failure to provide parameters for medication administration, and failure to document immunization education.
Complaint Details
The inspection was triggered by a complaint investigation KS#70617.
Severity Breakdown
SS=C: 1
SS=D: 5
SS=G: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to include screening and training of new employees and ongoing annual training for abuse and neglect in policy. | SS=C |
| Facility failed to revise care plans timely for residents after significant changes or procedures. | SS=D |
| Facility failed to ensure direct care staff were employed by the facility for 3 residents receiving care from private caregivers. | SS=D |
| Facility failed to provide timely effective fall prevention interventions and failed to monitor wanderguard system for residents at risk for elopement. | SS=G |
| Facility failed to meet nutritional needs of a resident resulting in 15.9% body weight loss in four months. | SS=D |
| Facility failed to identify parameters for blood pressure medication and blood sugars for two residents. | SS=D |
| Facility failed to provide documentation of education regarding benefits and potential side effects of influenza and pneumococcal vaccines for residents who declined immunization. | SS=D |
| Facility failed to clean food surfaces in a sanitary manner, label open food containers, and have appropriate drainage of the ice maker. | SS=F |
Report Facts
Census: 40
Weight loss percentage: 15.9
Fall risk score: 26
Weight measurements: 193.4
Weight measurements: 163.4
Blood pressure readings: Resident #40 blood pressure ranged from 208/103 to 112/70
Glucerna supplement frequency: 3
Insulin doses: 3
Lantus insulin dose: 25
Wanderguard checks missing: 2
Inspection Report
Annual Inspection
Deficiencies: 1
Jan 23, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a 'G' level. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions and possible termination of the provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'G' level deficiency. | G |
Report Facts
Effective date for denial of payment: Apr 23, 2014
Effective date for provider agreement termination: Jul 23, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Salierno | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter. |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 25, 2013
Visit Reason
This report documents a post-certification revisit to verify that previously identified deficiencies have been corrected as of the revisit date.
Findings
The revisit confirmed that the deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected on 02/25/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Feb 19, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#KS63822) regarding allegations of misappropriation of resident property.
Findings
The facility failed to report misappropriation of property for one resident and did not perform a thorough investigation, including lack of witness statements and failure to notify the State Agency.
Complaint Details
The complaint investigation found that the facility did not report the missing ring of resident #1 to the State Agency and failed to conduct a thorough investigation, including obtaining witness statements and interviewing other residents. The facility involved the police and ombudsman but did not notify the State Agency as required.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to report misappropriation of property for one resident and did not perform a thorough investigation. | SS=D |
Report Facts
Census: 39
Residents sampled: 3
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 19, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Claridge Court.
Findings
The Plan of Correction outlines the facility's commitment to thoroughly investigate all alleged violations, report incidents to the state department within five working days, and conduct audits to ensure proper documentation and protocol compliance.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as Claridge Court 021913 Complaint.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate and report alleged violations within required timeframes. | D |
Report Facts
Days to report incidents: 5
Audit completion date: Feb 25, 2013
Audit frequency: 3
Audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Salierno | Executive Director | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added the Plan of Correction. | |
| Mary Jane Kennedy | Modified the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 5
Aug 25, 2011
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as noted on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers F0225, F0280, F0323, F0329, and F0428 were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 5
Aug 2, 2011
Visit Reason
Health resurvey inspection conducted to evaluate compliance with regulatory requirements including investigation and reporting of abuse, care planning, accident prevention, medication management, and drug regimen review.
Findings
The facility failed to investigate and report an injury of unknown origin for one resident, failed to revise care plans related to falls and skin issues for multiple residents, failed to provide adequate supervision to prevent falls, and failed to obtain parameters for holding blood pressure medication and notify the physician accordingly. The pharmacist also failed to identify missing parameters for medication management.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to investigate and report an injury of unknown origin (skin tear) for Resident #18. | SS=D |
| Failed to review and revise care plans related to falls for Residents #36 and #32 and skin issues for Resident #18. | SS=D |
| Failed to provide supervision to prevent falls for Resident #36. | SS=D |
| Failed to obtain parameters for notifying physician for blood pressure and pulse and failed to notify physician when medication was held for Resident #32. | SS=D |
| Pharmacist failed to identify lack of parameters for notifying physician for blood pressure and pulse for Resident #32. | SS=D |
Report Facts
Deficiency count: 5
Resident census: 33
Sample size: 14
Inspection Report
Plan of Correction
Deficiencies: 2
N046036 POC M2KU11
Visit Reason
This document is a Plan of Correction submitted by Claridge Court in response to deficiencies cited in a prior inspection.
Findings
The Plan of Correction addresses deficiencies related to RN coverage and food handling practices, including staff re-education and monitoring plans to ensure compliance and prevent recurrence.
Deficiencies (2)
| Description |
|---|
| Failure to provide RN coverage for at least 8 consecutive hours a day, 7 days a week. |
| Failure to procure food from approved sources and maintain sanitary food handling, including proper use of hairnets/beardnets and food labeling. |
Report Facts
Corrective action completion date: Sep 16, 2016
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